Highland Baptist Church Medical Release Form

Consent for Medical Treatment 

In my legal capacity as parent/guardian of the minor participant named herein, in the event that my child becomes ill or is injured while on an authorized and chaperoned activity sponsored by Highland Baptist Church (whether on or off the church property), I give my permission and consent to the adult sponsors to administer first aid and/or CPR; to select a physician and/or hospital for my child’s care; to authorize emergency transportation service; and to authorize emergency medical care, including hospitalization, diagnosis, treatment (including dental or surgical procedures), administration of medication, radiology, anesthesia, and other interventions deemed necessary to my child upon the advice of a duly licensed physician, surgeon, or other qualified medical personnel. Further, I give EMS or any other emergency transportation service permission to transport my child if deemed necessary by the adult sponsors.

Limited Release

In consideration of Highland Baptist Church allowing my child to participate in authorized and chaperoned church-sponsored activities, I, on behalf of myself, of any joint parent/guardian, and of my child or ward, hereby 

• Waive and discharge claims against, release from liability, and indemnify and hold harmless Highland Baptist Church, its employees, agents, and adult sponsors (“Released Parties”) from any and all liability arising out of or related to any personal injury, illness, or other harm to my child in connection with the administration, selection, or authorization of medical care or emergency transportation as described above, even if caused by negligence of the Released Parties;
• Agree to indemnify and hold harmless Highland Baptist Church, its employees, agents, and adult sponsors from and against any and all claims, liabilities, damages, costs, or expenses (including attorney’s fees) arising out of the medical or emergency care provided to my child; the selection of any medical provider or facility; or any amounts claimed or billed by any medical provider, facility, emergency personnel, or emergency transportation service, including any EMS, ambulance, air ambulance, or other air medical services, whether or not such charges are covered by my insurance. 

This Limited Release does not in any way release any medical provider or entity other than Highland Baptist Church, its employees, agents, and adult sponsors.

I understand that this Consent and Limited Release will apply to all emergency situations present and future, and that a copy of this form is as valid as the original. This Consent and Limited Release form shall remain in effect until written revocation is given to Highland Baptist Church, or until the child is no longer a minor.

In my legal capacity as parent/guardian of the minor participant named herein, I agree that Highland Baptist Church may photograph and record my child’s likeness and activities during church related activities.

I grant Highland Baptist Church all rights to use these sound, still, or moving images in any medium, digital or print, for educational, promotional, advertising, or other purposes that support the mission of the church.

This Consent shall remain in effect until written revocation is given to Highland Baptist Church, or until the child is no longer a minor.

My child has my permission to be transported by designated group leaders from the Highland Baptist Church to and from all activities associated with PassportKids, June 17-20, 2025.  The mode of transportation will be the church bus and chaperone vehicles.  I further authorize Renee Kenley Purtlebaugh, Associate Pastor to Children and Their Families, and other designated group leaders to supervise my child during this event.